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BioMedCentral

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International Breastfeeding Journal

Open AccesResearch

Breastfeeding in Iran: prevalence, duration and currentrecommendations

Beheshteh Olang*1,2

, Khalil Farivar3

, Abtin Heidarzadeh4

,Birgitta Strandvik1,5and Agneta Yngve1,6

Address: 1Unit for Public Health Nutrition, Department of Biosciences and Nutrition, Karolinska Institute, Stockholm, Sweden, 2KermanshahUniversity of Medical Sciences, Kermanshah, Iran, 3Breastfeeding Office, the Ministry of Health IR of Iran, Tehran, Iran, 4Guilan University ofMedical Sciences, Rasht, Iran, 5Department of Pediatrics, Institute of Clinical Sciences, Gutenberg University, Gutenberg, Sweden and 6AkershusUniversity College, Lillestrom, Norway

Email: Beheshteh Olang* - [email protected]; Khalil Farivar - [email protected]; Abtin Heidarzadeh - [email protected];Birgitta Strandvik - [email protected]; Agneta Yngve - [email protected]

* Corresponding author

Abstract

Background: The need to promote breastfeeding is unquestionable for the health and development ofinfants. The aim of this study was to investigate prevalence, duration and promotion of breastfeeding status

in Iran with respect to the Baby Friendly Hospital, government actions and activities by the Breastfeeding

Promotion Society including comparison with European countries.

Methods: This retrospective study is based on data from 63,071 infants less than 24 months of age in all

the 30 urban and rural provinces of Iran. The data of breastfeeding rates were collected in 20052006 by

trained health workers in the Integrated Monitoring Evaluation System in the Family Health Office of the

Ministry of Health to evaluate its subordinate offices. A translated version of a questionnaire, used to

assess the current breastfeeding situation in Europe, was used.

Results: At a national level, 90% and 57% of infants were breastfed at one and two-years of age,

respectively. Exclusive breastfeeding rates at 4 and 6 months of age at national level averaged 56.8% and

27.7%. Exclusive breastfeeding rates at 4 and 6 months of age in rural areas were 58% and 29%, and in

urban areas 56% and 27%, respectively. The policy questionnaire showed that out of the 566 hospitals

across the country 466 hospitals were accredited as Baby Friendly Hospitals, covering more than 80% of

the births in 2006. A national board set standards and certified pre-service education at the Ministry of

Health. Iran officially adopted the WHO International Code of Marketing of Breast Milk Substitutes in1991. The legislation for working mothers met the International Labour Organization standards that cover

women with formal employment. The Ministry of Health and Breastfeeding Promotion Society were

responsible for producing booklets, pamphlets, breastfeeding journal, CD, workshops and websites.

Monitoring of breastfeeding rates was performed every four years and funded by the Ministry of Health

within the budgets assigned to the health care system.

Conclusion: In comparison to many European Union countries, Iran showed a favorable situation in

terms of breastfeeding rates and promotion of breastfeeding. Iran still needs to increase the rate ofexclusive breastfeeding during the first six months.

Published: 5 August 2009International Breastfeeding Journal2009, 4:8 doi:10.1186/1746-4358-4-8

Received: 5 November 2008Accepted: 5 August 2009

This article is avai lable from: http://www.internationalbreastfeedingjournal.com/content/4/1/8

2009 Olang et al; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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International Breastfeeding Journal2009, 4:8 http://www.internationalbreastfeedingjournal.com/content/4/1/8


BackgroundThe need to promote and support breastfeeding isunquestionable for the health and development ofinfants. It represents a public health priority everywhere,as confirmed by the Global Strategy on Infant Young

Child Feeding, unanimously approved by the 55th

WorldHealth Assembly (WHA) in 2003 [1].

Breastfeeding provides all essential nutrients for the first 6months of life. Breastfeeding plays an important role inensuring food security for a large proportion of babies inthe world, where food security is defined as havingenough food to maintain a healthy and productive lifetoday and in the future [2]. Breast milk contains the longchain polyunsaturated fatty acids which are especiallyimportant for the development of the brain and the nerv-ous system [3]. Breastfeeding is also associated with adecreased risk for many early-life diseases [4].

Low rates and early cessation of breastfeeding have impor-tant adverse effects on health, social and economic impli-cations for women, children, the community andenvironment, and results in greater expenditure onnational health care provision [5].

Health in Iran

Iran is an Asian country with 30 provinces spread over anarea of about 1,648,000 km2 and has about 70 millioninhabitants of whom 62% are living in urban and 38% inrural areas. According to UNICEF statistics in 2008 [6], thetotal fertility rate was 2 births per woman in 2006. The

infant mortality rate was 30 per 1000 live births and themortality rate in the population less than 5 years of age

was 34 per 1000 in 2006 [6]. It seems that child mortalityis going down over time and compared with other coun-tries in the East Mediterranean region Iran had a goodposition [7].

The average annual growth rate of the urban populationwas 4.9% during 19701990 and 2.5% during 19902006.The gross national income per capita was US$3,000 in2006. There were 850 active hospitals in Iran of which 566had delivery and neonatal wards. In the urban areas 500Health Centers provide health care and in the rural areas

this is provided by 18,000 Health Houses. Iran has 41Universities or Faculty of Medical Sciences (UFMS), all ofthem under jurisdiction of the Ministry of Health (MOH).

The capital province Tehran, has 12 million inhabitantsand is divided into three geographic regions, covered bythree different Universities of Medical Sciences (UMS)(Tehran 1 = Iran UMS, Tehran 2 = Tehran UMS and

Tehran 3 = Shahid Beheshti UMS).

The breastfeeding situation in Iran

The National Committee of Breastfeeding Promotion wasestablished at the MOH in 1991 by the Minister of Healthat that time, Professor Alireza Marandi [8]. The majorstrategy of the committee was to promote breastfeeding

for preventing morbidity and mortality in infants and toprogress their health.

The mission of the Children's Health Office in the MOHwas reviewed in 2004 [9]. It included 10 objectives: todecrease growth abnormalities in children due to malnu-trition, decrease mortality rates in both neonates andinfants, decrease mortality rate in children under 5 years,decrease mental and physical growth abnormality,increase the rate and duration of breastfeeding within thefirst two years of life, increase the percentage of exclusivebreastfeeding in infants up to 6 months, increase the per-centage of complementary feeding in 69 months children,

prescribe vitamin A and D and iron supplements andincrease the number of Baby Friendly Hospitals (BFHs).Exclusive breastfeeding is officially recommended in Iranuntil six months of age [9], with the addition of vitamin Aand D from two weeks after birth.

Each district in a province had a Health Network in whichthere was a breastfeeding committee. All committees atdistrict level were supervised by the main breastfeedingcommittee at the UFMS, located in the capital city of theprovince (Figure 1). Child health was monitored throughregular visits at Health Centers and Health House visitsfrom the first week of life until 24th month of age. Child

health monitoring was continued until 72 months afterbirth. At these visits the child was weighed, length andhead circumference measured and the general health sta-tus assessed. The vaccination programme was followed.Iran also has a private health sector but vaccination is per-formed by the MOH in more than 95% of children.

The exclusive breastfeeding rates up to 6 months in Mid-dle East-North African (MENA) region in the period of2000 to 2006 were 28% [6]. In the MENA region, exclu-sive breastfeeding rates in Pakistan, Iraq, Saudi Arabia,Egypt and Iran were 16%, 25%, 31%, 38% and 44%,respectively [6].

Based on Demographic Health Survey (DHS) statistics in2000 about 90% of the infants in Iran received any breast-feeding, while exclusive breastfeeding at 6 months wasless than 45%. The exclusive breastfeeding rate at 6months was about 44% in 2000 and decreased to 27% in2004 [9].

This study intends to clarify the current situation (2006)regarding breastfeeding rates as well as breastfeeding pro-
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motion and support in Iran, as a first measure to designappropriate measures to stop the downwards trend inbreastfeeding. This paper also reports on a survey of theimplementation of breastfeeding policies in Iran.

MethodsExclusive breastfeeding is defined as providing only breast

milk and no other liquids or solids except for those con-taining vitamins, minerals or medicines to the baby frombirth [10,11]. Exclusive breastfeeding is considered supe-rior at least until an infant is six months of age [10,12].

Breastfeeding rates were studied, using the IntegratedMonitoring Evaluation System Survey (IMES) which col-lects data regarding the content and consequences of pro-

vision and delivery health services for promoting healthin the country. The study population was obtained withregard to the general objective of IMES and on the basis of

data required for Family and Population Health Office ofthe MOH in 20052006. The study population was basedon data from IMES collected as follows: all mothers whohad given birth at hospitals or other health facilities, allmothers who had taken their infants for the first vaccina-tion at one of the rural or urban centers, all infants lessthan 2 years of age who lived in urban or rural areas and

had been referred to Healthcare Center or Health Houseto receive healthcare, vaccination or treatment for any dis-ease. It means that for exclusive breastfeeding rate data,only those infants were included who were between 1 dayand 6 months of age. However, for general breastfeedingdata, all infants were included (Table 1).

The data were gathered in urban and rural areas by healthworkers who were trained in the specifics of collectinghealth data including the definition of exclusive breast-feeding in the previous 24 hours. IMES data collection was

Health System Network and breastfeeding promotion organizational structure in IranFigure 1Health System Network and breastfeeding promotion organizational structure in Iran.
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performed in all rural areas through direct visits by trainedinterviewers who were employees of the MOH at UFMSand were sufficiently familiar with concepts and guide-lines of provision of healthcare as well as asking the IMESquestions through a questionnaire (see below). The ques-

tionnaire was validated in a pilot study in late 2004.Answers to questions about feeding patterns in infants at4, 6 and less than 24 month of age were made by mothersand were not the reviewers' opinion. Questions wereabout the name of province, district and health center,number of household, mother's age and education, birthdate, infant's age, weight, length and head circumference,breastfeeding exclusively and any breastfeeding. The data

were collected from 15 September 2005 to 15 January2006. In this paper only breastfeeding data are reported.

Sampling method and sample size (IMES)

We used a multistage sampling method with three kinds

of sampling:

1. Random cluster sampling with non-equal clusters. Ineach district we identified 20 clusters by random samplingfrom electrical power counters number list. Then two chil-dren were selected from each cluster to enter the study.

2. Sampling in the urban areas was from clients who cameto Health Centers for vaccination (convenience sam-pling).

3. Random systematic sampling was used to sampleinfants in rural areas. The sampling frame was the list of

childcare users which covered more than 99% of theinfants in rural area.

The policy questionnaire

In order to assess the current situation in regard to breast-feeding protection, promotion and support, a question-naire (available from the first author upon request) wasused during February to May 2007. This was a translationof one used in Europe [5,13]. The questionnaire was sentto the central committee of breastfeeding at the MOH,

where it was completed based on national data in 2006.

The questionnaire was used to investigate how the follow-ing topics were implemented in Iran as a whole and in itsprovinces:

1. Breastfeeding policy and/or action plans

2. Leadership for breastfeeding promotion

3. Training of health care staff

4. Baby Friendly Hospital Initiative (BFHI) [14]

5. Endorsement of the WHO International Code of Mar-keting for breast milk substitutes [15]

6. Legislation for working mothers

7. Community outreach, including mother support

8. Information, education, communication

9. Monitoring of breastfeeding duration and exclusiveness

10. Activities directed towards disadvantaged groups

Statistical analysis

IMES data were analyzed using STATA version 8.0 andSurvey Analysis commands by using each medical univer-sity as a separate strata and each data collection area as pri-mary sampling unit (PSU) and proportion of sampledperson to population of under 2 years of age infants as

weight. Breastfeeding rates were calculated with 95% con-fidence interval (CI).

Ethical approval

Approval to conduct this analysis was obtained from theethics committee at the MOH in Iran in February 2007.

ResultsThe number, age and the distribution of participants inthe IMES are shown in Table 1. The proportions between

Table 1: Number and percentage distribution of the study population; data from Integrated Monitoring Evaluation System

Age, months Total number Urban/rural%

Proportiondistribution

Cumulative %

04 2186 62/38 4.4 4.4

> 46 6248 61/39 10.8 15.2> 69 15833 56/44 20.5 35.7

> 912 5290 54/46 9.3 45

> 1218 17159 58/42 28 73

> 1824 16355 56/44 27 100

Total 63 071 57/43 100 100

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urban and rural provinces are shown, indicating that thestudy population was representative for Iran.

Breastfeeding rates (IMES)

At a national level, a mean of 90% (95%CI: 79.3, 96.1)

and 57% (95%CI: 33.1, 91.8) of infants had been breast-fed between 12 to 15 months and 20 to 23 months,respectively (Additional file 1; Table S1). The exclusivebreastfeeding rates were 57% (95%CI: 38.8, 79.6) at 4months and 28% (95%CI: 15.4, 52.7) at 6 months. Thedifferences in exclusive breastfeeding rates at 4 and 6months between regions are shown in Additional file 1;

Table S1.

The exclusive breastfeeding rates in rural areas were 58%(95%CI: 15.9, 87.6) and 29% (95%CI: 5.3, 53.8) at 4 and6 months of age respectively, and corresponding figures inurban areas were 56% (95%CI: 40.3, 81) and 27%

(95%CI: 12.7, 41.1) (Additional file 1; Table S1 and Fig-ure 2).

The exclusive breastfeeding rates at 4 and 6 months of ageand their confidence intervals are presented in Additionalfile 1; Table S1. The results vary from 30% to 94% at 4months of age and 13% to 55% at 6 months of age. Theregions with the lowest exclusive breastfeeding rate at 4month of age were Sistanblochestan, Qazvin and Yazd

with low, middle and high socioeconomic status (SES),respectively. The lowest exclusive breastfeeding rate at 6month of age was seen in Yazd, Isfahan and North Kho-rasan with high SESs. The highest rates could be seen in

North Khorasan (high SES), Kordestan (low SES) andArdebil (low SES) at 4 month of age. The highest rate ofexclusive breastfeeding at 6 month of age was in Ilam (lowSES), Guilan (middle) and Kohkilouyeh (low SES) (addi-tional file 1; Table S1). These results indicate that socioe-conomic status is not the most important factor formothers to breastfeed.

Policy, planning and management

All provinces and UFMS are supposed to follow thenational policy which is regulated by the MOH (Figure 1).Four objectives have been adopted by universities, includ-ing implementing the Ten Steps for Successful Breastfeed-

ing and helping mothers to initiate breastfeeding soonafter birth [16], to breastfeed exclusively for 6 months andto continue breastfeeding up to 2 years of age.

A national plan including general objectives and recom-mended strategies has been developed by the MOH [17].

Action plans including specific objectives, targets andactivities have been developed by health workers in allprovinces. All UFMS have a coordinator who shouldreport these activities to the national coordinator at theMOH on a regular basis. Members of the provincial com-

mittee are all chairs and vice chairs of UFMS, experts frommedicine, nursing and midwifery schools, pediatric nutri-tionists and gynecologists/obstetricians as well as nutri-tion departments in each province. The deputy of healthat each UFMS coordinates these committees.

Training

There is a national board that sets standards and certifiespre-service education at the MOH. The 18-hour UNICEF/

WHO course on promotion of breastfeeding and BFH hasbeen introduced by the MOH [18]. The 40-hour WHO/UNICEF course on breastfeeding counseling has beenintroduced by the MOH in all UFMS [19]. Most of thesecourses are endorsed and lead to credits. The training cov-ers nurses, midwives, general physicians, pediatriciansand obstetricians. Health workers have, in the majority ofcases, completed the 18-hour course and are in the proc-ess to completing the longer course, since they need it to

keep their positions. The course requirement in time is 36hours for physicians and specialists.

Baby Friendly Hospital Initiative

Each province has a BFHI coordinator in the provincialhealth center who reports to the Deputy of Treatment

Affairs in each UFMS. The proportion of births covered byBFHs is more than 80 percent. All BFHs are evaluatedannually by the Breastfeeding Office at the MOH. Eightytwo percent (466/566) of hospitals across the country

were accredited as BFHs in 2006. Additional file 1; TableS1 shows the number of BFHs by province and UFMS. Thenumber of BFHs in each province varies from 3 to 72. The

number of hospitals is related to the population in eachdistrict or province. The number of BFHs in relation to thepopulation varied from 0.28 to 1.31 per 100,000 inhabit-ants (Additional file 1; Table S1). The two provinces withlowest numbers of BFHs per 100,000 population wereQom and Sistanbalochestan, with 0.28 and 0.33, respec-tively. The two highest were in Yazd and Golestan with1.31 and 1.05, respectively (Additional file 1; Table S1).

The proportion of BFHs in relation to total number ofhospitals in the different provinces varied between 0.5and 1. The two lowest proportions of BFHs in relation tototal number of hospitals were seen in Qom and Kerman-shah with 0.5 and 0.56, respectively (Additional file 1;

Table S1).

WHO International Code and subsequent relevant WHA

resolutions

Iran officially ratified the WHO International Code ofMarketing of Breast Milk Substitutes in 1991 [20] and alsofavored of the International Code of Marketing of Breastmilk Substitutes and of subsequent relevant WHA resolu-tions. Iran adopted many provisions (e.g., no advertisingof breast milk substitute to the public, no direct and indi-rect free samples or gifts to mothers or their relatives, no
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Exclusive breastfeeding rates at 4 and 6 months of age in rural and urban areas, Data from Integrated Monitoring EvaluationSystemFigure 2Exclusive breastfeeding rates at 4 and 6 months of age in rural and urban areas, Data from Integrated Moni-toring Evaluation System.

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gifts or personal samples to health workers and etc) of theCode also in its directive for the internal market of infantsand follow on formulas.

Legislation for working mothers

The Maternity Protection act of the International LaborOrganization (ILO) [21] sets standards for protecting andsupporting breastfeeding in Iran only among governmen-tal working mothers and working mothers who haveinsurance that is paid for by themselves or their employ-ers. These standards include the provision of a minimum24 weeks of paid maternity leave as well as the right to onepaid breastfeeding break daily or reduction of work byone hour per day to promote longer duration of breast-feeding without loss of payment up to 24 months of age[22].

The ILO recommendations also state that maternity leave

payments should be at least two-thirds of previous earn-ings. This is adhered to completely by government institu-tions in all provinces of Iran. There are day care centersand kindergartens next to most of the governmentaloffices. Maternity leave from work was extended from 16to 24 weeks at the end of 2006. After six months, reduc-tion of work by one hour per day is optional, in order topromote breastfeeding up to 24 months of age. It isimportant to note that for mothers without insurance,

working outside governmental institutions, there is nopaid maternity leave or right to breastfeeding breaks.

Community outreach, including voluntary mother to

mother supportThe Iranian Breastfeeding Promotion Society (BFPS) [23]is a non-governmental, non-political and non-profitorganization, which was established in 1991. This societysupports mothers through a web site and telephone sup-port service. There is no special organization for mother tomother support [23].

Information, education, communication

The Breastfeeding Office at the MOH and BFPS (non-gov-ernmental) are responsible for producing pamphlets,booklets, leaflets, a breastfeeding journal, videos, CD, TVspots and web based information as well as workshops for

staff. CD and videos are used for training mothers andphysicians in BFHs. These materials are revised regularlyby the National Committee of Breastfeeding. The WorldBreastfeeding Week activities are implemented in all prov-inces by the MOH and in Tehran is partially by UNICEF.

There is also a governmental breastfeeding website [23].

Monitoring

Monitoring of breastfeeding rates is performed every fouryears by the Breastfeeding Office at the MOH within thebudgets assigned to the health care system.

Disadvantaged groups

All of the women in Iran have the opportunity to usematerial for breastfeeding promotion from the MOH.

There is a possibility for mothers without insurance toreceive monetary support from Emdad Relief Committee,

which is funded by public resources.

DiscussionThree important findings in our study were the identifica-tion of the rates of exclusive breastfeeding at 4 and 6months of age, and the high proportion of accreditedBFHs. The policy questionnaire showed that the Iranianauthorities have made many measures to improve motherand infant care. Despite those efforts there were large var-iations in breastfeeding rates, which were not easilyexplained.

Large provinces have UMS and small provinces have Med-

ical Faculty. The differences in number of BFHs were dueto difference in the number of hospitals in each MedicalUniversity or Medical Faculty (e.g. Jahrom district hasonly one Medical Faculty and one hospital which is aBFH). BFHs covered more than 80% of deliveries acrossthe country in 2006. BFHs had applied the WHO breast-feeding definition.

The highest exclusive breastfeeding rate at 6 month of agewas shown in Ilam, which is a small province with lowSES and a more rural population. It could be explained byold traditions that support breastfeeding in that area. Theproportions of BFHs in relation to total number of hospi-

tals and BFH to 100,000 population in Ilam were 0.71and 0.91, respectively. The highest exclusive breastfeedingrate at 4 month of age was in North Khorasan with a highSES and high education but the exclusive breastfeedingrate at 6 month of age had dropped off. It could beexplained by the return to work by mothers. The propor-tions of BFHs in relation to total number of hospitals andBFH to 100,000 population in North Khorasn were 1.0and 0.61, respectively. The lowest exclusive breastfeedingrate at 4 month of age was shown in Sistanbalochestanbut it was not the lowest exclusive breastfeeding rate at 6month of age. Sistanbalochestan has low SES and morerural and low educated population. There is seasonal

movement in this area. The proportions of BFHs in rela-tion to total number of hospitals and BFH to 100,000population in Sistanbalochestan were 0.88 and 0.33,respectively. The lowest exclusive breastfeeding rate at 6month of age was illustrated in Yazd with high SES, higheducation and early return to work. The proportions ofBFHs and BFH in relation to total number of hospitals to100,000 population in Yazd were 0.92 and 1.31, respec-tively. Qom had the lowest proportions of BFHs in rela-tion to total number of hospitals and BFH to 100,000population despite the exclusive breastfeeding rates at 4

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and 6 months of age were 54.4% and 25.8%, respectively.Also the urban population was higher than the rural pop-ulation in Qom province and the SES was high. Theregions with low rates of exclusive breastfeeding rate at 4and 6 months are characterized by low to middle SES and

also by return to work, while the North Khorasan andGuilan with high rates can be seen as affluent parts of thecountry, Ilam and Kordestan are regarded as culturallymore traditional and with a more rural population.

Higher rates of exclusive breastfeeding in rural areas com-pared with those in urban areas indicated that this situa-tion could be due to tradition rather than socioeconomicstatus or high education. A cross-sectional study in thenorth district of Iran (Babol) in 1998 showed that theprevalence of breastfeeding was 87% and 89% at 12months in urban and rural areas and 18% and 53% at 24months, respectively [24]. In our results the prevalence of

breastfeeding was 95% at 12 months in urban and ruralareas and 66.7% and 33% at 24 months, respectively. Onthe other hand in this area in our study there is no clearrelationship between high and low socioeconomic status,high and low proportion of BFHs and BFH to 100 000population and the breastfeeding rates, suggesting thatthe breastfeeding rate is determined by many interactivefactors.

Lower rate of exclusive breastfeeding in working mothersdemonstrate the need to educate mothers, but the exten-sion of paid maternity leave might be more important[25]. Other factors may be of importance and more

research is required for identifying explanatory factors.

The exclusive breastfeeding rate at 6 month of age wasabout 44% in 2000 and decreased to 27% in 2004. Ourfindings support the decreasing trend since in this studynearly 28% breastfed at 6 month of age. The Breastfeeding

Office became more active in late 2004, with supportfrom the National Breastfeeding Committee. Iran had nothad any International Board Certified Lactation Consult-ants (IBCLCs) until 2007 [26]. At the end of 2007, how-ever, the first coordinator was appointed who was

certified as an IBCLC. Furthermore paid maternity leave inIran was increased from 16 to 24 weeks in 2007. Iran hasa good family planning system; the growth rate of thepopulation is under control and mothers are encouragedto work outside the home and have fewer children.

The status of BFH in March 2002 demonstrated that thenumber of Baby Friendly Hospitals in the world was14,992, distributed over the eight regions [5]. The regionsare West and Central Africa, Eastern and Southern Africa,Middle East and North Africa (MENA), East Asia andPacific, South Asia, Americas and the Caribbean, Centraland Eastern Europe and the Commonwealth of Independ-

ent States (CEE/CIS) and Industrialized Countries. Iran islocated in the MENA region and had 376 BFHs in 2002.

Thus Iran, as 1 out of 20 countries had 46% of the BFHsin this region. Iran was the first ranked country in terms ofproportion of BFHs in the MENA region. Second and thirdranked countries were Tunisia and Egypt, which had 17%and 15% of proportion of BFHs in MENA region, respec-tively. At the same time Saudi Arabia and United ArabEmirates had even fewer proportions of BFHs (0.25% and0.5%, respectively). Despite the fact that Iran has a rela-tively good position from an international perspective;the MOH is planning to increase the number of BFHs. Bycomparison with some EU countries [5] Iran had an inter-

mediate situation in regards to the number of BFHs (Table2). Sweden had only a 34% exclusive breastfeeding rate at6 months of age in 2000 despite 100% BFH indicating thecomplexity of the subject [5]. A recent review, regardingbreastfeeding in Australia and Iran, showed that most

Australian women discontinue breastfeeding before the

Table 2: BFH prevalence, percentage of births at BFH and exclusive breastfeeding (Excl. BF) prevalence in some EU countries [5] and

Iran.

Country Year BFHs/total hospitals % of birth at BFHs Excl. BF at 4 mo. (%) Excl. BF at 6 mo. (%)

Austria 1998 14/110 12 79 46

Germany 1998 18/1100 3 33 10

Italy 2000 7/700 1 47 13

Lithuania 2002 3/54 12 _ 14

Portugal 1998 0/60 0 _ 9

Sweden 2000 52/52 100 68 34

Iran 2006 466/566 80 57 28
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recommended time [27]. The study attempted to identifyvariables influencing breastfeeding practices in Australiaby comparing Australia with Iran, indicating compara-tively high breastfeeding rate in Iran. Only approximately4.5% of public and private hospitals in Australia [27] were

BHF while the corresponding figure in Iran was 80%.

The breastfeeding tradition is well established in Iran, andthe history of breastfeeding can be traced back to thefourth century in the Canon Medicine Text Book which

was written by Avicenna [28]. This important textbookwas extensively used in European medical schools for cen-turies after Avicenna's death. In the Canon of Medicine, achapter was allocated to the care of the newborn infantdealing with hygiene, breastfeeding and raising the child.

ConclusionThe breastfeeding situation in Iran is good in comparison

with several European countries and Australia. However,the exclusive breastfeeding prevalence had shown a down-

ward trend at 4 and 6 months, which was confirmed inthis new study. The results were far from meeting the

WHO recommendation. The declining trend showedlarge big regional differences. Support for women needsconsiderable improvement in regards to the protection,promotion and support of breastfeeding, which wouldprobably increase the national figures substantially.

Competing interestsThe authors declare that they have no competing interests.

Authors' contributionsBO drafted the manuscript and coordinated the projectbetween the MOH in Iran and Karolinska Institutet. KF

was the head of Breastfeeding Office in the MOH andhelped for preparing data collection in policy question-naire. AB was responsible for IMES data and performedstatistical analysis. BS helped to developing the study and

writing the manuscript. AY participated in design of thestudy. All authors approved the final manuscript.

Additional material

AcknowledgementsSpecial thank goes to the Deputy Minister of Health, Dr. Emami Razavi, in

the Ministry of Health in Iran, the head of Population and Family Health

Office in the MOH, the head and members of the Breastfeeding Promotion

Society in Tehran and the head and members of breastfeeding office in the

MOH.

References1. WHO: Global Strategy on Infant and Young Child Feeding.

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Additional File 1

Table S1. Mean percentage of infants with exclusive breastfeeding

(EXBF) and 95% confidence intervals (CI) at four and six months (m)

of age and partial breastfeeding (BF) at one and two years of age in the

different provinces in Iran.

Click here for file

[http://www.biomedcentral.com/content/supplementary/1746-

4358-4-8-S1.doc]
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